Dispensing error - antihypertensive (01HDC10717)

A man presented to his GP with inadequately controlled blood
pressure. Instead of Accupril 10mg tablets, as prescribed, the
pharmacist dispensed Accupril 5mg tablets with a label stating that
they were 10mg tablets. The man also complained that on an earlier
occasion the pharmacist dispensed an incorrect dose of the
beta-blocker atenolol on a repeat prescription.

The importance of the checking process when dispensing
prescription medicines cannot be overstated. The Pharmaceutical
Society of New Zealand's Quality Standards for Pharmacy emphasise
the responsibility of dispensing pharmacists to maintain a
disciplined procedure in order to ensure that the appropriate
product is selected and dispensed correctly and efficiently.

The pharmacist acknowledged his errors, apologised and reimbursed
the man. He also revised the pharmacy's Standard Operating
Procedures.

The Commissioner held that the pharmacist breached Right 4(1) in
that he failed to take reasonable care and skill when checking and
dispensing the prescriptions. As the pharmacy had taken reasonable
steps to prevent the error that occurred, it was not vicariously
liable for the breach of the Code. The matter was referred to the
Director of Proceedings, who decided not to issue proceedings.